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Gastroenterology
Urinary Incontinence in Women



Urinary Incontinence in Women
How the Urinary Bladder Works
Kidneys

If you are like most women, you take your urinary system for granted - until it causes problems. Most of us have enough going on in our busy lives and don't have time to worry constantly about how our bladder is doing.

Actually, your urinary system is really an amazing piece of work. Every time you eat, your body absorbs fluids into your blood stream. Every day, the billions of cells in your body generate waste products that are toxic and must be removed. Your two kidneys constantly filter your bloodstream to remove excess fluid and toxins from your body. This excess fluid, or urine, is transported down each ureter (YOUR-eh-tur) and stored in your urinary bladder (not to be confused with your gall bladder) until it is socially acceptable to empty. The bladder is a balloon-shaped muscular organ that changes shape as it fills with urine.

Located at the bottom of the bladder, there is a valve called the urethral sphincter (SPHINK-ter). It is like a miniature blood pressure cuff wrapped around the urethra (yoo-REE-thrah). This sphincter keeps the bladder closed by tightly squeezing the urethra. Pelvic floor muscles help hold your bladder in its proper place. Urine stays inside your body when the pelvic floor and sphincter muscles are tight and the bladder is relaxed. Control of urine is called continence (CON-tin-entz). Good bladder control means you urinate only when you want to. To maintain continence, all parts of your system must work together.

  • Pelvic muscles hold up the bladder and urethra.
  • The urethral sphincter keeps the urethra closed.
  • Nerves work in concert to control the muscles of the bladder, and pelvic floor.
Like most bodily functions, the act of urination is complex. At first, the bladder fills up like a plastic bag without an increase in pressure. Eventually, however, the bladder walls begin to get stretched. As the pressure rises, and you begin to realize that your bladder is getting full. Usually, after you reach this amount (which varies widely from person to person), you can still hold some more urine and your bladder fills a little more.

At some point however, no matter how hard you try, you can no longer hold your urine. These feelings of fullness are sent to your brain from special nerves in the bladder wall. It is this feedback from your bladder to your brain that lets you know when it is time to search for a restroom. When it is appropriate to empty your bladder, you voluntarily relax the pelvic floor muscles, contract the bladder muscle, and release the urethral sphincter which "opens the drain". This allows the urine to voluntarily flow out through the urethra.

What is Urinary Incontinence?

When your bladder involuntarily empties without your conscious control, this is called Urinary Incontinence (in-CON-tin-entz). Urinary incontinence is a significant problem in the United States. It ranges from mild leakage to uncontrollable and embarrassing wetting. Women are much more likely than men to experience loss of bladder control. Factors responsible for this are pregnancy with the trauma of childbirth, menopause with its low estrogen levels, and the very anatomy of the female urinary tract. In fact, over 13 million people suffer with incontinence, but less than half of those affected with incontinence seek help. Many accept it, thinking it is normal with age and resort to absorbent or sanitary products. Others avoid social situations where they could be embarrassed by urinary leakage, and risk social isolation.

Contrary to popular opinion, however, most incontinence is treatable and manageable. Incontinence is not normal. Once properly evaluated, it is often curable and is always able to be treated.

Tests to Evaluate Urinary Incontinence?

Take the Incontinence Quiz

A urine culture is the first test, because it is necessary to eliminate a urinary tract infection as a cause of the symptoms. A Voiding Diary is the next step. A record of all fluid intake and urine output is kept over a 24 hour period. This is reviewed by Dr. Wharton, and depending on the Diary, the Physical Examination, and the Medical History a plan is developed. This plan may include further urodynamic testing. Some of these test are:

 

    Complex Cystometrogram - This is a high tech, electronic study. By measuring and recording 6 separate functions, we can see how well the bladder stores and empties urine. The study takes about 20 minutes to complete, and the most uncomfortable sensation is the feeling of a full bladder.

    Urethral Pressure Profile - This test measures the strength of the urethral sphincter. Using a small pressure sensor, pressure readings are recorded all along the length of the urethra. From this, the maximum strength and length of the urethra are measured.

    Complex Uroflowometry - This test measures how well the bladder empties, and the storage capacity of the bladder.

    Cystoscopy/Urethroscopy - Sometimes the inside of the bladder and urethra must be examined. Using a narrow scope and a camera the bladder can be examined to make sure there are no tumors, stones or polyps causing symptoms. The physician and patient are able to watch the entire examination on a television screen. The most uncomfortable symptom encountered with any of this testing will be the sensation of a very full bladder.

Types of Urinary Incontinence

There are actually many different types of incontinence. Some of these are: genuine stress incontinence, intrinsic sphincter deficiency, urge incontinence (overactive bladder), overflow incontinence, and mixed incontinence. Mixed Incontinence is a combination of two or more of the previous types of incontinence. Just as there are different types of incontinence, there are different treatments. Some respond only to surgical repair while others responds to therapeutic treatment such as: medication, biofeedback, and pelvic floor exercises.

Many people have had a treatment for incontinence that has failed to cure the problem. In these circumstances, the underlying problem was probably not identified correctly before the treatment was instituted. Since incontinence has so many different causes, a careful evaluation must take place in order to find the specific cause of the urinary loss; otherwise, the treatment is certain to fail.

Genuine Stress Incontinence

Genuine stress incontinence is the most common of all types of urinary incontinence. Depending on which study is quoted, it represents 15-52% of all cases incontinence. There are different factors that predispose a woman to genuine stress incontinence. A few of these are:

    1. Having four or more children.
    2. Increased prevalence with age.
    3. Being overweight.

With stress incontinence, there is an anatomical defect present which allows the bladder and the urethra to be displaced downwards. This causes a failure of the normal continence mechanisms. Treatment for this problem is directed at the underlying cause, which is to restore the support for the bladder or the urethra.

Bladder training with Kegel exercises may improve control in some women. These simple exercises can strengthen the pelvic floor muscles, and take only a few minutes a day. The exercise is done by tightly contracting the pelvic floor muscles and sphincter, as you would do to shut off the flow of urine for about four seconds at a time. Do at least 50 a day. No one has to know you're doing these exercises. Kegels can be done during virtually any activity.

Pelvic Floor Rehabilitation can be used to help strengthen these muscles. Rehabilitation consists of consists of biofeedback, electrical stimulation, and pressure monitoring. Biofeedback measures the small electrical currents produced by the contracting muscles of the pelvic floor. These electrical currents are displayed on a TV monitor so that the woman can watch patterns change as her muscles contract. She can then learn only to flex specific muscles, while consciously relaxing others. Electrical stimulation causes muscles to contract, and can be used to help strengthen weakened muscles, or direct a woman's attention to muscles she needs to exercise. Vaginal pressure sensors can monitor directly, the strength of these muscles.

Milder forms of stress incontinence may respond to pelvic floor rehabilitation, the more severe forms may not.

Some patients find a pessary very useful in preventing embarrassing accidents. A pessary, which is a plastic or silicone prescription device, is inserted into the vagina to support the bladder and urethra. The pessary fits into the vagina like a diaphragm and by supporting the bladder helps restore continence. It must be custom fit as each person has a unique anatomy, and it should be removed and cleaned daily.

Surgical approaches are useful in patients who have more severe forms of stress incontinence, or who have failed or are not satisfied with more conservative measures. Because of the physical nature of stress incontinence, many patients do require a surgical procedure for correction of the problem. There are many different procedures done to correct stress incontinence. The goal of each is to re-support the bladder neck to prevent its downward movement. Surgery is notalways lengthy and it may be as simple as an outpatient or an in-office procedure. If, however, there are other associated problems, such as a dropping bladder, or poor support of the uterus, it may require a hospital stay.

The injection of compounds to help strengthen the urethral sphincter can be performed right in the office. The urethral sphincter is visualized using a cystoscope and either Contigen or Duraspheres are injected around the sphincter. Contigen is an implant made from collagen which is first obtained from cows, and then highly purified. Collagen is a natural protein that provides texture and shape to tissues under the skin. These compounds have the effect of strengthening the action of the urethral sphincter. Duraspheres are non-absorbable, ultra fine polymer spheres. They act the same as Contigen in strengthening the urethral sphincter, but last forever. Contigen injections may need to be repeated.

Urethral slings are usually performed as an outpatient, or overnight stay. This minimally invasive procedure offers a very high cure rate and has stood the test of time. It requires small incisions, one in the vagina and one in the lower abdominal wall just above the hairline. Newer surgical techniques require only one vaginal incision and can be done as an outpatient or overnight stay. This approach is made possible by placement of graft tissue to support the urethra and bladder.

The treatment for relief of genuine stress incontinence should be tailored to what is best for the patient. If there are associated symptoms such as a cystoceole (hernia of the bladder) or a fallen bladder, a vaginal approach may be chosen. In this procedure, the defect of the fallen bladder or uterus can be repaired and usually reinforced with graft tissues to prevent it from recurring in the future. At the same time, the problems of urinary loss can be addressed and corrected. This allows the patient to have correction of the anatomical defects, return of urinary control, and a smoother, less painful post-operative course.

Certain medical conditions, such as an enlarged uterus or endometriosis, may require a hysterectomy to be performed. This is usually done through an abdominal incision. Procedures for restoration of continence can be performed at that same time through an abdominal incision. A decision on which procedure to do and which approach to take is a complex one and should be discussed with the patients needs and wishes kept clearly in mind.

Intrinsic Sphincter Deficiency

Intrinsic sphincter deficiency is a specific subtype of genuine stress incontinence. It is caused by a faulty sphincter between the bladder and the urethra. With a cough, sneeze, or mild exercise, this defective sphincter allows urine to leak from the bladder into the urethra and out of the body. Treatments are the same as for stress incontinence, which is mentioned above.

Urge Incontinence

Urge incontinence is the second most common type of urinary loss. It is present in 2-13% of all cases. It manifests itself by a sudden onset of a severe urge to void followed by a loss of urine. You may feel strong, sudden urges to go to the bathroom, even if your bladder has a small amount of urine. Unlike stress incontinence, an anatomical defect is not always present. The urge sensation may occur spontaneously or it may be linked to certain activities or trigger events. Frequently, activities such as arising from bed or standing from a sitting position may cause a sudden contraction of the bladder. Other people have the severe urge brought on by washing their hands or taking a shower. This type of incontinence usually responds very nicely to medical therapy or a combination of medical therapy and biofeedback. Pelvic floor rehabilitation can help with this type of treatment, and health insurances will usually cover up to six physical therapy visits.

Pelvic floor rehabilitation helps some women retrain the muscles that control continence. This is usually done over several office sessions. A physical therapist places a sensor patch over the muscles, which displays the muscle contractions on a TV monitor. You watch the screen to see if you are exercising the right muscles. Soon you learn exactly how to control these muscles without the sensors and TV screen. Urge incontinence has the best response to pelvic floor rehabilitation. There are also a few medications available that reduce the degree of urinary incontinence. Ditropan XL is a once-a-day tablet prescribed for the treatment of overactive bladder, which may have symptoms of urge incontinence episodes (wetting accidents), urgency (a strong need to urinate), and frequency (urinating often). The most common side effect is a dry mouth.

Detrol (tolterodine tartrate tablets) is another medication approved by the FDA for urge incontinence. In clinical trials, Detrol reduced the number of times patients urinated by about 50%. Detrol should not be used in patients with urinary retention, gastric retention, and uncontrolled narrow-angle glaucoma. Other medications, including oxybutynin (Ditropan), propantheline (Pro-Banthine), and imipramine (Tofranil) are also used for urge incontinence.

Overflow Incontinence

In overflow incontinence, the bladder is not emptying properly. After voiding, a medium to large volume of urine remains in the bladder. Because of this, it takes only a small amount of urine to give a feeling of fullness again. The effect of this condition is to cause frequent episodes of emptying small volumes. The primary cause of overflow incontinence is usually neurological in nature. This may be spinal damage, diabetes, strokes, or other nerve damage. Again, non-invasive treatments are available for this type of problem.

Other Treatments

Some individuals with mild incontinence can benefit by other treatments. Simple measures such as reducing excess fluid intake, and avoiding caffeine may be helpful. Sometimes double voiding-trying again a few minutes later-helps. In post-menopausal women, estrogen replacement therapy or estrogen vaginal cream is sometimes helpful in stress and urge incontinence.

Successful Treatments are Available

No matter what type of incontinence a person has, it can have a major impact on their life. It inhibits social activities and causes embarrassment. Many people with incontinence pull away from their family and friends. They try to hide the problem from everyone, even their doctors. The lesson to be learned is that with today's level of understanding of incontinence problems, most women can be very successfully treated and the she can return to her normal social activities. Treatment can be planned only after the cause is clearly defined. Successful treatments are available.

Copyright:
Keith H. Wharton, M.D


Text & Images Courtesy of Three Rivers Endoscopy Center
© Dr. Robert Fusco, Three Rivers Endoscopy Center, All Rights Reserved





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